CLINICAL RECORD FORM

ADMINISTRATIVE & SELF-REPORT INFORMATION (May Be Completed by Patient)

Patient: ___________________________________________ Date of Birth: ___/___/___ Age:

Address:

City: _________________________________________________ State: ________ Zip:

Telephone: Work (____) _______________ Home: (____) ____________ Cell: (___)

Health Plan ID#: ___________________________ Subscriber S.S.#: _________-_________-

Employer/School:

Sex: □ Male □ Female Marital Status: □ Married □ Single □ Divorced □ Widowed

Emergency Contact: ___________________________________________ Telephone: (____) ___________

Parent/Guardian (if relevant): Name:
Address: _____________________________________________________ Telephone: (____)
Current Medical Conditions:

Current Medications, Herbal Supplements & Vitamins (Daily Dose, Start Date, Name of Prescriber):

Allergies/Adverse Reactions to Treatment:

Primary Care Physician Name:

Address: ______________________________________________________ Telephone: (____)

Reason for Seeking Evaluation Today:

Patient Signature: __________________________________________________________ Date: _______________

(Pages 2-6 To Be Completed By Clinician)

Presenting Problem:
Clinician Name, Degree/License: __________________________________________ Date: _____________ 1
Prior and Current Treatment for Mental Health, Alcohol or Other Drug Problems:

Past and Present Use of Cigarettes, Alcohol and Other Substances (Date of First Use, Most Recent Use, Use in
Past 3 Months; Legal, Vocational and Family Consequences):

Psychosocial History (for children and adolescents, include pre-natal and post-natal events and developmental history):

Patient Name: Date: ________________

Clinician Name, Degree/License: __________________________________________ Date: _____________ 2

CURRENT MENTAL STATUS EVALUATION: (Please check all that apply)

APPEARANCE: [ ] Well-groomed [ ] Disheveled [ ] Bizarre [ ] Inappropriate

ATTITUDE: [ ] Cooperative [ ] Guarded [ ] Suspicious [ ] Uncooperative

[ ] Belligerent [ ] Other ________________________________________________

MOTOR ACTIVITY: [ ] Calm [ ] Hyperactive [ ] Agitated [ ] Tremors/Tics

[ ] Muscle spasms [ ] Other _________________________________________________

AFFECT: [ ] Appropriate [ ] Labile [ ] Expansive [ ] Constricted

[ ] Blunted [ ] Flat [ ] Worrisome [ ] Sad [ ] Apathetic

MOOD: [ ] Euthymic [ ] Depressed [ ] Anxious [ ] Euphoric [ ] Angry

SPEECH: [ ] Normal [ ] Delayed [ ] Soft [ ] Loud [ ] Slurred

[ ] Excessive [ ] Pressured [ ] Incoherent [ ] Persevering

THOUGHT PROCESS: [ ] Intact [ ] Circumstantial [ ] Tangential [ ] Flight of ideas

[ ] Loose associations
[ ] Other

THOUGHT CONTENT:

Hallucinations: [ ] Not present [ ] Present

If Present, describe: ________________________________________________________

Delusions: [ ] Not present [ ] Present

If Present, describe: ________________________________________________________

SUICIDE/HOMICIDE: See Next Page

ORIENTATION: [ ] Fully oriented [ ] Disoriented

If Disoriented, describe:_____________________________________________________

MEMORY: Long-Term [ ] Intact [ ] Impaired

Short-Term [ ] Intact [ ] Impaired
If Impaired, describe: ______________________________________________________

COGNITIVE FUNCTION:

General Knowledge: [ ] Intact [ ] Somewhat intact [ ] Not intact

Serial Sevens/Calculations: [ ] Intact [ ] Somewhat intact [ ] Not intact
Abstract Thinking: [ ] Intact [ ] Somewhat intact [ ] Not intact

JUDGEMENT: [ ] Intact [ ] Impaired – [ ] Mild [ ] Moderate [ ] Severe

INSIGHT: [ ] Intact [ ] Impaired – [ ] Mild [ ] Moderate [ ] Severe

Patient Name: Date: ______________

Clinician Name, Degree/License: __________________________________________ Date: _____________ 3

Suicidal Risk:
Suicidal Ideation? [ ] Yes [ ] No
Current plan/intent to harm himself/herself? [ ] Yes [ ] No
Hx of any previous attempts? [ ] Yes [ ] No

Homicidal Risk:
Homicidal Ideation? [ ] Yes [ ] No
Current plan/intent to harm others? [ ] Yes [ ] No
Hx of any previous attempts to harm others? [ ] Yes [ ] No

Legal Issues (Current and Past):

Other Risk Issues:

Mental Status Comments:

Patient Name: Date: ________________

Clinician Name, Degree/License: __________________________________________ Date: _____________ 4

Structured Rating Scale Results:
If you use any standardized instruments as part of your assessment, put your findings here. We suggest using
instruments to complement your clinical assessment for depression (such as the PHQ-9:
http://www.pfizer.com/pfizer/phq-9/index.jsp ), Alcohol Disorders (such as the AUDIT: see
www.niaaa.nih.gov and search on AUDIT for info), and Anxiety Disorders (such as Panic Disorder and Generalized
Anxiety Disorder).

Depression Findings ______

Anxiety Findings ______

Alcohol Abuse/Dependence Findings ______

DSM-5 Diagnosis: Code Description

Insight Specifier (Good, Poor, Absent)

Diagnosis Specific Severity Scale (DSM-5 pgs. 733-738)

Differential Diagnosis

Patient Name: Date: ________________

Clinician Name, Degree/License: __________________________________________ Date: _____________ 5
Treatment Plan
Specific Target Sx/Behaviors: Interventions (Related to Goals): Estimated Time for resolution:

Does patient understand and consent to proposed treatment plan? Yes □ No □ :

If “no,” explanation:

Were referrals to other services (i.e., medication evaluation) or patient education provided? Yes □ No □
If so, description (including preventive services):

If patient was prescribed psychotropic medication, was informed consent obtained? Yes □ No □

Provide date of initial prescription, name and dosage, instructions and if applicable, dates of refill.
Date Medication Name Dosage Instructions (e.g. one BID) Refills

Patient Name: _____________________________________________________________ Date: _____________

Clinician Name, Degree/License: __________________________________________ Date: _____________ 6

BEHAVIORAL HEALTHCARE COORDINATION FORM

Responsible practice requires coordination of care with other treating professionals and healthcare delivery systems as clinically
appropriate. Consider using this form (or one with comparable information) to send to your client’s Primary Care Physician or
other healthcare provider (not to MHN) if he or she meets any of the following criteria:
_ Is taking prescribed psychotropic medications
_ Has reported a concurrent medical condition
_ Has a substance use disorder
_ Has a significant mental illness (condition other than an adjustment disorder)
_ Was referred to you by a PCP or other medical practitioner, or
_ If a PCP will be following the patient for psychotropic medications
_ Was referred to you following a psychiatric admission or ER service

Name of Patient: Patient ID Number:

Information exchanged for purposes of treatment, payment and healthcare operations is permitted under the Health Insurance Portability and
Accountability Act (HIPAA) even without a member’s authorization to do so. A member’s authorization is required only before behavioral health
practitioners share psychotherapy notes (session notes kept separate from the medical record consisting of the contents of conversation during a
private, group, joint, or family counseling session) which are not included in this form.

PCP or Other Healthcare Professional Who Is Also Providing Care

Name Fax #

Address Phone #

***********************************************************************************************
Dear Doctor: Today’s Date:
The above named patient is receiving behavioral health services. Date of First Session:
Current Diagnosis:

Current Psychotropic Medications

MEDICATION DOSAGE START DATE PRESCRIBED BY

Coordination of Care Issues

Behavioral Health Practitioner

Name Fax #

Address Phone #

This information has been disclosed to you from records whose confidentiality is protected by confidentiality provisions of most states’ law and applicable federal
law. Under such law, you are prohibited from making any further disclosure of these records without the specific written consent of the person to whom they pertain
or as otherwise specifically required or permitted by law. A general authorization for the release of medical or other information is not sufficient for this purpose.
Federal regulations under 42 CFR Part 2 restrict any use of the confidential information to criminally investigate or prosecute any alcohol or drug abuse patients.
 PROGRESS NOTES [COPY AND USE ONE PROGRESS NOTE PAGE FOR EACH SESSION]

Session #: ____
Patient progress towards goals (including patient’s strengths/limitations):

Interventions and patient’s response:

Revised goals or interventions:

Check any of the following that apply and explain actions taken (i.e., list any referrals made):
Suicide Risk □ Homicide Risk □ Diminished Activities of Daily Living □ Judgment Risk □

Document all of the following (if applicable):

 Laboratory test results
 Mandated reports
 Prevention/Referrals to community services
 Coordination of care with other clinicians, consultants, healthcare institutions or programs
 Discharge plan (For final session, document tx summary, discharge plan and patient status)

Follow-up appointment date:

Clinician Signature, Degree/License: ___________________________________________________ Date:_________

Patient Name or ID Number: